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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> k FFICE USE: 1601 E. Hazelton Ave,,. Stockton, CA 95205 Permit No.`s9 7_7 y <br /> Telephone: (209.) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Date Issued -`i <br />! (,Complete In Tripl+i-cate) <br /> Application is hereby made to the San Joaquin Local , Health ,District for a permit to; construct <br /> and/or install the work herein described. This application is made in compliance with San <br /> t Joaquin County Ordinance Na. 1862 and the Rules and Regulations of -the San Joaquin Local' Health <br /> District. <br /> EXACT STREET ADDRESS <br /> CI -/TOWN <br /> Owner's Name Phone ?_ <br /> Address City <br /> License# Phone - <br /> Contractor's Name � - - <br /> IS CERTIFICATE OF WORKMAN'S COMPENSATION INSURANCE ON FILE WITH-SJLHD? YES NQ <br /> xTYPE 4F WORK (Check) : �NEW WELLT0 j"DEEPEN 0 ` RECONDITIONS] DESTRUCTION[] <br /> WELL CHLORINATION Q WELL `ABANDONMENT 0 OTHER ( <br /> . w, PUMP,,INSTALLATION C7 PUMP -REPAIR0-- PUMP REPLACEMENT <br /> . DISTANCE TO NEAREST: _--S.E.P..T-L --TANK --- --S-E-M- � c� <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGEPte— OTHER <br /> PROPERTY LINE - PRIVATE .,DOMESTIC WELL .-_-__._ PUBLIC DOMESTIC WELL <br /> " INTENDED USE �. TYPE OF-WELL... i -,CONSTRUCTION SPECIFICATIONS <br /> -' Indus ,-, .� <br /> trial .. '` <br /> )t t: Ca61e Tool k Dia: ofyle 1 Excavation <br /> Qomestic/pr1yate,, Dri-1,1 D a. of Well Casing - <br /> _ `-Dornsti c/publ`i c - Driven Gauge "of Casing <br /> 'Irrigats_-on � .3 -x '} Gra-vel Pack Depth of Groiat:, Sea <br /> - Cathodic Protection Rotary Type, of Grout - . <br /> -- Disposal Other, t-r Other Information <br /> Geophysical `'y; �:�• ; yr ` jf, : :��� - Surface Seal Installed <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: State Work pone <br /> PUMP REPAIR: ❑State Work Done _ <br /> DESTRUCTION OFWELL: Well Diameterr �--- <br /> AP-rox mate Depth <br /> Describe Material and Procedure <br /> I hereby' certify that I have prepared this application and that the work will be done ' iri accordan( <br /> with San' Joagdin County 'Ordinances , State Laws., and Rules and Regulations of the;San Joaquin- Local <br /> Health District. Home owner or licensed agent's signature certifies the following: <br /> "I certify that in the performance of the work for which this permit is issued, I shall <br /> not employ any.person in such manner as to become subject to Workman's Compensation <br /> laws 'of California.. <br /> I WILL CALL F R A GROUT NSPECTION PRIOR TO GROUTING AND A_EIN& INSPECTION. <br /> t SIGNED _ - <br /> k TITLE: DATE:Y--- <br /> R W PLLTN ON REV SE SIDE <br /> iIFO R EPAR MENT U ONLY <br /> PHASE I � � --� y' �- r , <br /> APJ <br /> PLICATION ACCEPTED BY ` ' . DATE G � <br /> ADDITIONAL COMMENTS: <br /> PHASE II. GROUT INSPECTION <br /> :INSPECTION BY _ PHASE III FINAL INSPECTIO <br /> ' . 'DATE 'f. ti.,INSPECTION BY �r DA 7 . 6112 <br /> H 14 26 Rev. 9/78 R <br /> Y9/78` ' '2M <br />